Clinical Innovators | Garth Graham, MD, MPH: Reducing Disparities in Cardiovascular Health

Interview by Katlyn Nemani

Garth N. Graham, MD, MPH, is the assistant dean for Health Policy and chief of the Health Services Research Section in the Department of Medicine at the University of Florida School of Medicine, as well as the co-director of the UF Clinical and Translational Science Institute Implementation Science Program. His prior public health work includes serving as the Deputy Assistant Secretary at the US Department of Health and Human Services, where he coordinated federal health policy that addressed the needs of minority and underserved populations. The Business Network Journal named him one of the “Forty Leaders Under Forty,” Modern Healthcare Magazine named him one of the “Top 25 Minority Executives in Healthcare,” and the ACC awarded him the inaugural credo award for his work in reducing cardiovascular disparities.

In this edition of Clinical Innovators, we discuss disparities in cardiovascular health and interventions to improve care with Dr. Graham.

You led efforts to reduce health disparities in both the Bush and Obama administrations. What are our biggest challenges in minority health and health disparities?

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By 2050, it is predicted that non-Hispanic whites will no longer be the majority, with increased numbers of Hispanics, Asians, and people of multiple races (Figure). With these predicted shifts in population demographics, well-known racial and ethnic health disparities will become increasingly prevalent. Because cardiovascular disease (CVD) remains the predominant cause of morbidity and mortality, understanding how to treat this changing population is critical for improvements in care. I think that some of our biggest challenges and greatest opportunities will be interventions targeted at eliminating racial and ethnic disparities in this arena.

When addressing challenges in minority health, it is important to distinguish between health care differences and disparities. The definition, as adopted by the Institute of Medicine, identifies health care disparities as “racial or ethnic differences in health care that are not due to access-related factors, clinical needs, patient preferences, or the appropriateness of the intervention.” Thus, a greater prevalence of hypertension in African Americans or diabetes in Hispanics represents differences, whereas a smaller rate of treatment to goal may indeed represent disparate care.

Could you tell us more about the unique risk factors and disparities in CVD that affect minority populations?

Disproportionate rates of CVD are seen in minority populations. Minorities have a greater burden of myocardial infarction, heart failure, stroke, and other cardiovascular events; these disparities translate to inequitable cardiovascular morbidity, mortality, and quality of life. Importantly, CVD-related deaths occur much earlier in minority populations compared to the rest of the population.

African-American adults have among the highest rates of hypertension in the world, and have poorer blood pressure control even after consideration of modifiable health behaviors—suggesting that other racial/ethnic differences underlie these disparities. Studies to discern unique characteristics of hypertension in African Americans have found, for instance, that aldosterone correlates significantly with several CVD risk factors associated with obesity-related hypertension in this population. N-terminal prohormone brain-type natriuretic peptide also appears to be an independent biomarker for predicting CVD events in African Americans with kidney disease and hypertension. A better understanding of the unique risk factors and predictive biomarkers affecting this population will be essential to improving their cardiovascular health.

Hispanics present with higher risk profiles for CVD but have lower rates of coronary heart disease and CVD mortality than whites, regardless of their diabetic status. Some data suggest that coronary artery calcium is present in lesser amounts in Hispanics. A difference in risk factors and either prevalence of CVD or subclinical disease has also been seen in Mexican Americans, though their risk profiles were unique compared to individuals of other Hispanic backgrounds. Further study is required to better understand this paradox of risk and disease and to appreciate the intra-group differences seen among Hispanics.

South Asians have elevated risks of morbid and mortal events due to ischemic heart disease (IHD), and they have not benefited to the same extent from the general decline in deaths caused by IHD over the last few decades. Chinese, South-Asian, and Southeast-Asian patients are likely to exhibit classic symptoms of acute MI—but are less likely to seek care in a timely manner. More than 30% of patients in this group wait longer than 12 hours to seek treatment, whereas whites are more likely to seek medical attention and undergo angiography within 3 hours of onset.

CVD risk factors remain poorly defined in other racial/ethnic minority populations, particularly for American Indians and Alaska Natives due to a lack of data. Systematically assessing and quantifying modifiable CVD risk factors is critical in minority populations. Understanding and talking about the disparities of CVD risk factors by different communities may help clinicians develop prevention initiatives and services specifically targeted toward risk factor modification in each of these populations.

What are the most promising solutions and interventions to improving disparities in cardiovascular care?

The solutions around racial and ethnic disparities are really multifactorial. Research is important, as are efforts to disseminate that research and improve the quality of care delivered. The ongoing role of prevention and early detection is also key.

In terms of research, the burgeoning populations of Hispanics, Asians, African Americans, and Native Americans should be incorporated in future trials to help us better understand their unique CVD presentation and optimal interventions. Community-based efforts, proven to be beneficial, must be identified. There are a number of medications and treatment strategies that we know improve the health of individuals with CVD, but we need to work to disseminate those strategies to the broader population including underserved communities outside of the ivory towers.

How can we broadly disseminate strategies found to be effective?

That’s where the field of implementation science holds the most potential. Implementation science is the study of methods to promote the integration of research findings and evidence into health care policy and practice. It seeks to understand the behavior of health care professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidence-based interventions.

What is the role of prevention?

Although racial and ethnic disparities clearly exist within the CVD population, we are really more alike than we are different. Obesity has a negative impact on all ages, all racial/ethnic groups, and both sexes. Caloric management through proper nutrition and physical activity is universally important. Body mass index and waist circumference are inversely associated with fitness, with low fitness most significant in non-Hispanic African Americans and Mexican Americans.

Lifestyle interventions should be universally applied, but it must be noted that risk assessment is a unique challenge in certain populations. For example, current guidelines to identify metabolic syndrome underestimate the risk in South-Asian individuals. Recent reports of a novel hypertension screening program in African-American barber shops hold great promise as well as programs that incorporate faith- based settings where communities are more receptive to appropriately tailored health messages. Culturally sensitive prevention programs that incorporate such nuances will help mitigate disparities.

How can individual cardiologists and other clinicians contribute to reducing disparities in care?

We practitioners of cardiology have the opportunity to lead the charge in reducing racial, ethnic, and sex-based disparities and must do so by embracing a greater cultural awareness of the patients we serve. We must acknowledge that race is a non-physiological assignment and reflects more on the cultural experience and the aggregation of the social determinants of health than on a specific biology.

We should seek to understand nuances in presentation, risk factors, and decision making in different racial and ethnic groups. Cultural competency, which has been defined as the ability “to provide care to patients with diverse values, beliefs, and behaviors including tailoring delivery of care to meet patients’ social, cultural, and linguistic needs,” is a new skill that will require the same awareness as clinical practice guidelines if we are to achieve best care for all who are at risk for or who have CVD. The importance of respecting language and literacy differences cannot be overstated.

Delivering the best cardiovascular care in an increasingly diverse community will require a universal focus on prevention; an unyielding embrace of an evidence-based, quality-focused approach; novel research initiatives; and specific treatment sensitivities tailored to the cultural context of our patients. Decreasing racial/ethnic disparities must become a priority at the patient, provider, and systems levels. Although additional research is needed, increased awareness on the part of practicing physicians is an essential and immediate next step. The time has come to no longer simply recognize our increasing diversity and evident health care disparities, but to embrace our diversity and achieve true health equity.

How will the implementation of health care reform influence disparities in care?

Health care reform has tremendous potential for reducing health disparities. With a focus on increasing coverage, the implementation of health reform could possibly provide health insurance coverage to millions of individuals from underserved populations. When coverage is improved, health disparities are reduced.

One example of this can be found looking at TRICARE, which provides health care coverage for the Department of Defense’s service members, dependents, and retirees. A recent study examined disparities in health status, access to care, satisfaction with care, and preventive care for TRICARE beneficiaries. The study found fewer racial and ethnic health disparities among TRICARE beneficiaries as compared to racial and ethnic minorities in the civilian population. While the study found that some disparities do exist, the fewer disparities for TRICARE beneficiaries could be attributable to equitable access to high-quality health care. So we do know that increasing coverage can reduce disparities. This is where health reform holds its greatest promise.

Do you have any advice for clinicians or researchers interested in blending a research and policy career?

I have had the unique experience of being able to work on research, policy, and patient care directed at underserved communities. In doing this I have had great mentors—Dr. John Ruffin at NIH, Dr. John Rich at Drexel, Dr. Roger Blumenthal at the Cicarone Center for the Prevention of Heart Disease. I have worked to blend these experiences into a career that translates research into policy and positively impacts the lives of those who need the most help.

My advice would be to find individuals whom you respect and learn from them and then follow a path that reflects your passions. There are huge opportunities now to improve health outcomes for individuals at the local, national, and international level—and we need talented individuals with unique skills and backgrounds who are committed to making a difference.

Katlyn Nemani, MD, is from Tufts University School of Medicine in Boston.

Keywords: United States Dept. of Health and Human Services, Ethnic Groups, Health Policy, Patient Care, Health Care Reform, Insurance Coverage, Decision Making, Healthcare Disparities, Health Services Research, Social Determinants of Health, Minority Health, Institute of Medicine (U.S.), Awareness, Public Health, Vulnerable Populations, Quality of Life, Cardiovascular Diseases, Health Services Needs and Demand, Risk Assessment, Patient Preference, ACC Publications, CardioSource WorldNews

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